PHARMACISTS

We're here to help answer your questions about member eligibility and benefit plan information, claims processing, and payment/remittance questions.

(888) 832-2779

Available 24/7 including holidays

For any legal or clinical information, please send to:

Capital Rx Attn: Prior Authorization
9450 SW Gemini Dr., #87234, Beaverton, OR 97008

Forms & Documents

Pharmacy Provider Manual

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Capital Rx Provider Manual is a guide for network pharmacies that includes policies and procedures including, but not limited to, contact information, term definitions, claims processing information and pharmacy network participation requirements.

Last updated: December 2023

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Reversal Payer Sheet

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Reversal Payer sheets provide data requirements needed to electronically process NCPDP pharmacy claim reversals for each line of business within Capital Rx. Each line of business will have a designated reversal payer sheet for reference when a pharmacy chooses to reverse claims submitted to Capital Rx from their pharmacy system.
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Last updated: October 2021

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Electronic Remittance Advice Enrollment

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If you have questions regarding your pharmacy remittance advice, please outreach to ap@cap-rx.com.

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Prior Authorization Request Form

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To submit a prior authorization (if required), please complete the prior authorization request form and fax it (along with any additional documentation required) to (833) 434-0563.

Prior authorization request forms can also be sent via mail to the below address:
Capital Rx
Attn: Prior Authorization
9450 SW Gemini Dr., #87234
Beaverton, OR 97008

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Pharmacy Reimbursement Appeals

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The specific state specific additional requirements below for Arkansas, Mississippi, New Mexico, and Tennessee.

Pricing appeals must be submitted within 30 days from the date the claim was filled or within the time period required by applicable state law. Pricing appeals that are submitted outside of this timeframe may NOT be reviewed.

Note that pricing appeal submissions with missing information will be invalid and excluded from review. As permitted with applicable law, pricing appeal reviews of any individual claim from a pharmacy are final and will NOT be reviewed again.

Please note that the Capital Rx pricing appeal review process does not provide clinical advice nor direction for product substitutions. Please refer to your state substitution laws.

Questions related to the pricing appeals may be submitted to pricing.appeals@cap-rx.com or 833-502-1220.

TN Appeal Form State Specific Requirements Capital Rx Appeal Form

Payer Sheet

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Payer sheets provide data requirements needed to electronically process NCPDP pharmacy claims for each line of business within Capital Rx. Each line of business will have a designated payer sheet for reference when setting up Capital Rx BIN/PCN numbers into the pharmacy system.

Last updated: November 2023

Download Commercial COB 1 PDF Download Commercial COB 2 PDF Download Medicare PDF

Electronic Funds Transfer (EFT) Enrollment Form

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If you have questions regarding your pharmacy payments please reach out to ap@cap-rx.com.

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Direct Member Reimbursement Form

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Please call us at (888) 832-2779 and our support team will work with you to validate the member's eligibility.

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Formulary Look-Up (Open/Freedom)

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Please call us at (888) 832-2779 and our support team will work with you to validate the member's eligibility.

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Formulary Look-Up (Closed/Liberty)

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Please call us at (888) 832-2779 and our support team will work with you to validate the member's eligibility.

Click Here

Explore pharmacist resources

Our number one priority is ensuring the health and safety of our members through access to over 65,000+ retail pharmacies.

Pharmacy Help Desk Services

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Payment or Remittance Questions

Frequently Asked Questions

What BIN number is used to adjudicate claims?

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Our BINs 610852 and 610770 adjudicate on Capital Rx's platform. For additional information on these BINs, please consult the payer sheet for Capital Rx.

What do I do if I cannot confirm a member's eligibility?

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Please call us at (888) 832-2779 and our support team will work with you to validate the member’s eligibility. If for any reason the issue cannot be resolved in real-time, please suggest that the patient pay for the prescription upfront and, once the eligibility error has been corrected, submit a paper claim to us. DMR form can be found here.

What should I do if a member thinks that his/her out-of-pocket obligation is incorrect?

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Please call us at (888) 832-2779 to verify the patient pay amount.

Who do I contact for payment/remittance questions?

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Please send your questions to ap@cap-rx.com.

What do I do if a claim rejects?

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Please call us at (888) 832-2779 and our support team will work with you to resolve the rejection as quickly as possible.

How long does a prior authorization review take?

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Most prior authorization reviews are completed within two business days provided that a complete prior authorization request form and all required documentation are correctly submitted. Our clinical team will notify you in advance of any declinations and assist in expediting your patient to a preferred alternative therapy.

How can I join the Capital Rx pharmacy network?

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To join our network, please contact us at provider.relations@cap-rx.com.